So You Found An Exchange Plan. But Can You Find A Provider?

New York University's Langone Medical Center in New York City is considered in-network for relatively few of the health plans offered in the state marketplace.

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Originally published on November 3, 2013 4:51 am

Consumers shopping for coverage on the new health insurance exchanges have been focused on the lowest-cost options. But some shoppers are trying to determine which plans offer the widest array of doctors and hospitals — and are finding that can be trickier than it sounds.

John Batteiger applied for insurance coverage on the New York state exchange. But after he'd selected a plan, he had second thoughts: He'd forgotten to check if the plan he picked included a hospital near him.

Batteiger is 54 and healthy. But all things being equal, he figures, why not make sure his neighborhood hospitals are considered "in-network" with his insurance plans?

After a little hunting and pecking, Batteiger learns that a nearby hospital, Lenox Hill, was not in the first plan he chose. Eventually he did find a plan that includes Lenox — and also brings his monthly premium down from about $290 to $230 per month.

"To save $60 a month — that's a really good thing," Batteiger says.

It's safe to say, however, that not everyone will be so lucky. New York City has a lot of hospitals to choose from, but many of them are considered in-network for only a few insurance plans. Sarah Thomas, vice president of public policy and communications at the National Committee for Quality Assurance, says health plans get better deals by limiting the number of in-network hospitals.

"If a health plan can say, 'Instead of five hospitals in this city, we're [going to] have three,' then those three hospitals that are included in the network might be able to give some discounts to the health plan," she explains.

Insurers and hospitals are often locked in a tug-of-war over prices. Smaller clinics and doctors' offices have a lot less leverage than hospitals — but they also need to make decisions about which insurance networks to join. And many are sitting on the sidelines.

Dr. Neil Calman, president of Family Health Institute, serves low-income residents in the Bronx, many of whom have complex health needs. He says some of the plans are offering "extremely low" medical reimbursement rates.

"They claim that they are putting their premiums out on the street at a very low rate to make them affordable," he says. "But we can't afford to see a patient for the same amount of money that a private doctor in their office with one assistant can."

Calman accepts five plans. A handful of others wanted to pay him less than what he receives from Medicaid.

A trade association of New York doctors polled its members and found that three-fourths of them are either not participating in exchange plans or are unsure if they are.

Benjamin, the health exchange navigator, is also a senior policy adviser at the Community Service Society, which aids lower-income families. She says New York has done a good job generally making sure the all policies have enough in-network providers — but things are still in flux.

"It is a game of musical chairs. The providers and the health insurance companies are still ... the music's still playing," she says. "But eventually the music will stop, and then we'll really have a strong sense of who the actual provider list is."

And that will continue happening over the next few years.

Benjamin printed out a comparison chart for her client, Batteiger, of the plans he's considering purchasing.

Batteiger, who's been uninsured since June, says he's not worried about finding a personal physician who accepts this or that plan, since he'll be starting from scratch, anyway.

But for other consumers who care about going to particular hospitals or doctors, Benjamin advises calling those offices before signing on to a plan.

Americans shopping for coverage on health insurance exchanges are still encountering problems. Some are getting through and selecting insurance plans often based on costs. But as Fred Mogul from member station WNYC reports, some consumers are trying to figure out which plans offer the best selection of doctors and hospitals too.

FRED MOGUL, BYLINE: Manhattan resident John Batteiger applied for insurance coverage on the New York State exchange and he selected a plan but was having second thoughts. He realized he forgot to figure out...

JOHN BATTEIGER: Will the plan that I signed up for have a hospital near me?

MOGUL: Batteiger is 54 years old and healthy, but he figures all things being equal, why not make sure his neighborhood hospitals are in network with his insurance plan? It's not so easy to figure out. So he and Elisabeth Benjamin, a health exchange navigator, are in a Manhattan office doing some digging.

ELISABETH BENJAMIN: So what facility were you interested in?

BATTEIGER: Right near me there's Lennox Hill and Presbyterian.

BENJAMIN: Let's try Lennox Hill.

MOGUL: After a little hunting and pecking, it turns out Lennox Hill was not in the first plan he chose, but he did find a plan that includes it and brings his monthly premium down from about $290 to $230.

MOGUL: It's safe to say not everyone will be so lucky. New York City has a lot of hospitals to choose from, but many of them are in-network for only a few plans. Sarah Thomas from the National Committee for Quality Assurance says health plans get better deals by limiting the number of in-network hospitals.

SARAH THOMAS: If the health plan can say, you know, instead of five hospitals in this city we're going to have three, then those three hospitals that are included in the network might be able to give some discounts to the health plan.

MOGUL: Insurers in hospitals are often locked in a tug of war over prices. Smaller clinics and doctors officers have a lot less leverage than hospitals, but they also need to make decisions about which insurance networks to be in. And right now, many are sitting on the sidelines. Dr. Neal Calman runs the Family Health Institute.

DR. NEAL CALMAN: Some of the plans are offering us extremely low rates.

MOGUL: And that's saying a lot. He serves low-income residents in the Bronx, often people with complex health needs.

CALMAN: They claim that they are putting their premiums out on the street at a very low rate to make them affordable, but, you know, we can't afford to see a patient for the same amount of money that a private doctor in their office with one assistant can do.

MOGUL: Calman accepts five plans. He rejected a handful of others that wanted to pay him less than what he gets from Medicaid. A trade association of New York doctors polled its members and found three-fourths of them not participating in exchange plans or unsure if they will. Elizabeth Benjamin, the exchange navigator, is also a senior policy advisor at the Community Service Society, and she says New York state has generally done a good job making sure the policies all have enough in-network providers, but things are still in flux.

BENJAMIN: It is a game of musical chairs. The providers and the health insurance companies are still kind of - the music's still playing, they're still trying to figure out who's in who, but eventually the music will stop and then we'll really have a strong sense of what the actual provider list is.

MOGUL: And this process will take a few years to sort out. Benjamin printed out a comparison chart for her client, John Batteiger, of the plans he's considering purchasing.

BENJAMIN: Do you want me to put this all in an envelop? And come back any time or call me if you need to do anything else, and we're all set.

BATTEIGER: Well, I've got a lot of reading and comparing to do.

MOGUL: Batteiger, who's been uninsured since June says he's not worried about finding a personal physician who accept this or that plan because he'll be starting from scratch anyway. Benjamin advises other consumers who do care about going to particular doctors or hospitals to call those offices first. For NPR News, I'm Fred Mogul in New York.

SIMON: And this story's part of a partnership among NPR, WNYC and Kaiser Health News.